Abstract
This article describes a cross-sectional survey conducted in Melbourne which investigated the physical health status of people with mental illness. The study used a range of health measures for which Australian population data existed. This enabled comparisons to be made between the mentally ill and other Australians. Major differences were found in the prevalence of risk factors for cardiovascular disease and HIV infection. Despite the study population seeing health professionals as often as other people, little advice or intervention to reduce these elevated risks is offered. This phenomenon requires further investigation as well as interventions to ensure that people with mental illness receive holistic health care and the same health promotion interventions that are available to the wider community.
Australians have experienced unprecedented improvements in health and longevity in the last four decades.[1] However, these benefits have not been uniformly distributed among all Australians. Population surveys indicate that indigenous Australians and those with low socio-economic status have not experienced the same health benefits as other people. Another group for whom health benefits have not been forthcoming are the mentally ill. However, unlike indigenous status, education and income, history of mental illness is not collected in population health surveys and the health discrepancy between the mentally ill and other Australians is not recorded. The lack of relevant data may partly explain why health programs targeting the mentally ill are virtually non-existent.
Mortality rates, which are used to assess health across and within populations, clearly demonstrate that the mentally ill experience far worse health than other people.2–5 After controlling for unnatural causes of death (suicide and accidents), people with mental illness are still significantly more likely to die in larger numbers at younger ages. Estimates of standardised mortality ratios for natural causes of death range from 1.65[6] to 4.26.[4] In particular, the mentally ill are more likely to die from cardiovascular and respiratory diseases. High rates of unprotected sex, multiple partners and injecting drug use also suggest that the mentally ill may be the new high risk group for HIV.[7], [8] Studies from the United States indicate that HIV prevalence among people with chronic mental illness ranges from 4% to 23%.[9]
The current study was designed to document the prevalence of health risks and health behaviours among people with chronic mental illness. People with mental illness were compared to the general population on key health indicators to estimate differences in health status. The results will inform the development of future interventions and provide a baseline against which interventions can be evaluated.
METHOD
Setting and sample
Two hundred and thirty-four clients of four Area Mental Health Services (AMHS) within the North Western Health Care Network Mental Health Program in Melbourne were interviewed about their health behaviour and underwent a brief physical examination.
Several recruitment methods were used to maximise participation rates. Clinic staff were informed about the project and encouraged to be involved in the recruitment process. Introducing the project to patients via their psychiatrist or case manager was an effective recruitment method. Many case managers felt that their clients would either enjoy discussing their physical health or would benefit from the awareness raising aspect of the interview. Another successful recruitment method involved the researcher obtaining permission from case managers to approach patients in the waiting room to explain the aims and requirements of the project and to request participation. A small number of participants were recruited when they contacted the researcher after seeing notices in the clinic advertising the project. Patients were excluded from participation if they were judged by their case manager to be too unwell; unable to understand the concept of informed consent; unable to speak English and an interpreter was not available; or they were unwilling to participate.
Measures
A survey instrument was designed to measure behaviour regarding physical exercise, smoking, diet, alcohol and caffeine consumption, sexual behaviour, drug use and use of preventive health services. Information was also collected regarding previous diagnoses of diabetes, hypertension and hyper-cholesterolaemia. In addition, participants underwent a brief clinical examination in which measures of height, weight and blood pressure were taken. A urine sample was collected and tested for the presence of glycosuria, proteinuria and haematuria. The interview and examination took approximately 30 minutes and were conducted in a private room in the clinic.
Criteria for inclusion of measures in the survey instrument included demonstrated reliability and validity in previous studies, appropriateness for use with people with mental illness and comparability with Australian studies for which there is large scale population data. Table 1 shows the domains measured in the survey and identifies the source of each measure.
Surveys of sexual behaviour typically target specific groups such as high school students or gay men. The only study of HIV risk behaviour in an Australian population[16] was conducted in 1988. Although it examined the prevalence of heterosexual and homosexual sex, essential information in determining HIV risk, such as condom use, was not collected. Neither did the study distinguish between casual and primary sexual partners. A new measure of sexual behaviour was developed by incorporating items from the instrument developed by Volavka[17] and based on discussions with experts in the field.
Questionnaire domains and measurement source
Four additional items were included in the questionnaire to obtain information on psychiatric diagnosis, current medications, first year of contact with mental health services, and year of most recent psychiatric admission. The questionnaire was piloted among volunteers at a psycho-social rehabilitation centre for people with mental illness.
RESULTS
Ninety-eight women and 136 men participated in the study. Because a convenience sample was used it is difficult to accurately assess refusal rates. Approximately 20% of clients approached by the researcher refused to participate. However, it is possible that some patients refused via their case manager who did not subsequently inform the researcher. Records across the four clinics indicate that approximately 1, 782 clients are currently active at any one time. On this basis, the current sample of 234 represents 13% of the clinic population. Convenience samples are more subject to bias than other sampling procedures. In this study, the sample was more likely to include more severely ill outpatients who attended the clinic frequently, thereby increasing their chances of being approached to participate.
Sample characteristics
The most common primary diagnosis for the sample was a psychotic disorder (79%), followed by Major Depressive Disorder (9%), Bipolar Disorder (4%), Personality Disorder (4%) and other disorders (3%). Just over half (51%) of the sample had had at least one psychiatric admission in the last 12 months and a further 17% had been hospitalised in the last three years. Age at onset of illness was estimated from first contact with psychiatric services or hospital admission. For 16% of the sample, illness onset occurred in the three years prior to the interview. A further 29% became ill between three and nine years previously, 32% between 10 and 19 years and 22% had been living with a mental illness for more than 20 years.
Compared to the PRISM data base, which records information on all clients in the Mental Health Program, the sample was representative in terms of gender distribution: men comprised 58% and women, 42%. PRISM indicates that the typical gender distribution of outpatients across the clinics is 55% men and 45% women.
Twenty per cent of 18 to 65 year olds in the Body & Mind Project were married or in a de facto relationship compared to 59% of other Australians between 20 and 64 years of age.[18] Just over half (51%) of the study participants lived with family, either with their parents or partner and/or children. In contrast, 85% of other Australians live with their family. People with mental illness were much more likely to live alone (29% cf. 8%) or to live with non-family members (20% cf. 7%). Very few participants were currently employed and 92% received a government pension as their main form of income. Compared to Australia as a whole, the current sample were more likely to have been born in a non-English speaking country (27% cf. 18%). However, PRISM indicates that compared to the proportion of NESB patients in the Mental Health Program, they were slightly under-represented in the study (27% cf. 34%). In particular, Vietnamese clients were under-represented.
Cardiovascular risk
Study participants were more likely than the general population to take up smoking and less likely to quit, resulting in a significant increase in smoking rates (62% cf. 24%). Men were more likely than women to smoke (68% cf. 54%). People with mental illness were just as likely to walk as were respondents in the Risk Factor Prevalence Study[11] but much less likely to engage in the moderate to intense physical activity that may protect against cardiovascular disease. Only 19% of the mentally ill undertook light exercise in the previous two weeks compared to 30% of other Australians. Similarly, only 12% had engaged in any vigorous exercise compared to 35% of respondents in the Risk Factor Prevalence Study. Twenty-eight per cent of the sample were overweight (25–29 kg/m2) and 40% were obese (kg/m230).
HIV risk
Drug use among people with mental illness was high. Respondents in the current study were twice as likely as people in the National Drug Strategy Household Survey[13] to have used illicit drugs in the last 12 months, and 13 times more likely to have used heroin. Fourteen per cent of participants had injected drugs and 8% reported sharing injecting equipment at some stage in their lives.
Only 4% of men reported sex with another male and only 1% of women reported having sex with a bisexual male in the past year. Less than half (46%) the participants had been sexually active in the past 12 months. Of those who had been sexually active, 32% of men and 10% of women had multiple (3+) partners in the past year.
Health service use
Relatively few differences were found between the study group and the general population in terms of preventive health checks and health service usage. Compared to other Australians, people with mental illness were only slightly less likely to have visited a GP or a dentist in the past 12 months, and were somewhat more likely to have had their blood pressure measured. They were just as likely to have had their blood cholesterol checked and women in the study group were just as likely as other Australians to have had a mammogram or a pap smear.
DISCUSSION
The high rates of obesity and smoking, combined with low levels of exercise found in this study may contribute to the excess of cardiovascular related mortality among people with a psychiatric illness. Consistent with other studies, people with mental illness were significantly more likely than others to smoke.19–21 The rates of smoking found in this study are lower than some studies which have reported rates as high as 88%.[22] However, they are consistent with a recent survey of nearly 1000 Australians living with a psychotic illness which reported smoking rates of 73% for men and 56% for women.[23]
Obesity is a major problem for the mentally ill. The prevalence of obesity among the sample was comparable to a recent Sydney based study of 38 people who were residents of mental health residential houses[24] which found that 37% of people with mental illness were obese and a further 34% were overweight.
The findings on service use indicate that people with mental illness were just as likely as others to use preventive health services. However, one of the major questions raised by this study is: If people with mental illness are visiting preventive health services as often as other people, why is their risk for serious physical disease so much higher? Are people with mental illness receiving the same services as other people when they visit a health professional?.
A recent study examining predictors of weight and exercise counselling by US physicians found that patients who were over 30 years of age, married, of higher socio-economic status, or obese were more likely to receive exercise counselling.[25] Patients who were uninsured, had Medicaid insurance or were sedentary, were counselled less often. Another study, using the same data set, found that the health and demographic characteristics of patients were also associated with physician counselling on weight loss.[26] Women, those with high education levels, people who were obese, and people who rated their health as fair to poor rather than good to excellent were more likely to receive weight loss counselling.
These studies suggest that people who are most at risk of lifestyle related illnesses (people with low socio-economic status and those who are sedentary) are least likely to receive preventive counselling. Instead, counselling is provided as a secondary intervention when obesity is already present. Galuska and her colleagues[26] suggest that physicians may tend to counsel those people who, they believe, are most likely to make positive lifestyle changes, inadvertently precluding those patients most at risk. She suggests that physicians may be pessimistic about the ability of patients with low income, low education and low activity levels to make lifestyle changes.
The current study has demonstrated that people with chronic mental illness have low socio-economic status and they are more likely than other Australians to be sedentary. It is currently unknown whether Australian doctors have similar counselling styles to their US counterparts. However, if they do, in fact, counsel those patients whom they perceive as most likely to undertake change, and neglect those for whom they are pessimistic, then people with mental illness may in fact be missing out on advice from medical staff which has the potential to moderate the high rates of cardiovascular risk factors.
In addition to a possible lack of weight loss counselling for the mentally ill, there is growing concern that the newer atypical antipsychotic medications cause additional weight gain. If this concern is well founded we can expect the prevalence of obesity to rise as more patients are prescribed the newer medications. Given the associations between obesity and chronic disease the current results may forecast further increases in cardiovascular related deaths.
The lifetime prevalence of injecting drug use confirmed earlier findings reported by Thompson et al.[7] Injecting drug use among patients attending community mental health clinics is considerably higher than among the general Australian population. These results suggest that the risk of blood borne communicable diseases among the mentally ill is high. Although information on HIV and hepatitis C status was not formally recorded, and the actual prevalence of HIV among the sample is unknown, it was observed by the researcher that many participants who reported that they had ever injected illicit drugs also reported that they were hepatitis C positive.
While some have suggested that individuals with chronic mental illness are asexual,[27] several studies have clearly demonstrated this is not so. For example, Cournos et al.[28] surveyed patients with severe and persistent mental illness and found 44% had been sexually active in the preceding six months. Our data are consistent with this and several other similar reports.[7], [29], [30]
The findings here with respect to injecting drug use and sexual activity suggest that the answer to the question posed by Stefan and Catalan[8] in a review article entitled “Psychiatric Patients and HIV Infection: A new population at risk” may well be Yes!
ACKNOWLEDGEMENT
This research was supported by a project grant from The Victorian Health Promotion Foundation